Answer_Book / Documentation_Guidelines_for_EM_Services / AMOUNT_AND_OR_COMPLEXITY_OF_DATA_TO_BE_REVIEWED

Article Overview

This documentation-guideline article for evaluation and management services covers how data review contributes to the overall record of medical decision making. It focuses on the types of diagnostic information that may be reviewed, including outside records and information from sources other than the patient, and on the kinds of documentation that support that review. The article is useful for physicians, coders, auditors, and documentation specialists who need to understand what broad categories of evidence should appear in the medical record.